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Underground Storage Tank Program - Farm Tank Information Form <br /> FACILITY/SITE INFORMATION (Complete this form for each FARM TANK location.) <br /> F FARM or BUSINESS NAME CONTACTNAME <br /> A B�l1Uf/f/ <br /> C ADDRESS(Stat address of TANK location) PHONE k (with arca code) <br /> I <br /> L <br /> I CITY STATE I ZIP CODE I NEAREST CROSS STREET <br /> T <Gl/ cfl 9.52410 7/'Z otW A.41� <br /> Y CHECK HERE if this ADDRESS should be used for Legal Notification <br /> JAN <br /> OPERATOR INFORMATION &ADDRESS (Complete If information different from above.) N 8 <br /> O NAME G(� �jE�� , j(�6C OPERA"!'ORLON"CACPNAtvlL`' <br /> E MAKING or STREET ADDRESS OPERATOR PHONE N (with area code) <br /> R <br /> T CITY STA'IB ZIP CODE <br /> 0 SWCf' . y'Wez 14W S&912 <br /> - <br /> R ✓ CFIECK HERE is this ADDRESS should be used for Legal Notification. <br /> PROPERTY OWNER INFORMATION &ADDRESS (Complete if different from above.) <br /> NAME OWN ER CONTACT NAME <br /> 0 <br /> NMAILING or STREET ADDRESS OWNER PHONE N(with area code) <br /> E <br /> R CITY STATE ZIP CODE <br /> CHECK HERE if this ADDRESS should be used for Legal Notification <br /> CHECK APPROPRIATE BOX <br /> T ACTIVE FARM TANK SITE (One or more underground TANKS > 1,100 gallon capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (AU.underground TANKS at site = to or < 1,100 gallon capacity) <br /> E ✓ PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNDERGROUND TANK INFORMATION (List additional tank Information on separate sheet If needed.) <br /> T TANK SIZE CHEMICALS STORED ESIIMAI'[il)DATE LAST USED MITIIOD OF CLOSURE DATE OF REMOVAL Olt <br /> A (GALLONS) CURRENTLY OR PREVIOUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE.IN PLACE <br /> N <br /> K <br /> I <br /> N <br /> F <br /> O <br /> TIUS FORM HAS BEN COMUNDER PENALTY OF PERJURY,AND T'O TIIE REST OF MY KNOWLEDGE,IS TRUE AND CORIA'C"T. <br /> NAME TITLE DATE 2-3 <br /> OFFICE USE ONLY <br /> SW[iEPS N (OMEN DE DLS'1'CODE N ACIIVE IKi'I' N UG'.MYI'UG'IN CL(ASED Uri] I SWEET'S PItOM/SUD CODE DA I V <br /> EH 23 044(12/a8) <br />